Treatment-withdrawal decisions in intensive care units: effects on nurses

The decision to withdraw treatment from patients in ICU's follows careful consideration of the facts about illness-severity and the potential for reversibility. Ethical principles are the foundation for decision-making but there are many facets to be considered in the process. The final decision to withdraw is taken when it is established that further treatment is futile. The effects of such decisions on the nurses involved were explored in a retrospective, descriptive, two-phase study.In phase one, 47 nurses from 12 ICU's were questioned about specific situations involving patients in their care. Questionnaires yielded qualitative and semi-quantitative data about (a) the decision-making process and participants in it; (b) the reasons nurses gave for supporting, or disagreeing-with; the decision taken; (c) revisions to the treatment-plan made as a consequence of the decision; and (d) the roles of nurses. Feelings were also ascertained about nursing activities, together with views on the best and worst aspects of the situations described. Data revealed both satisfying and troubling aspects for the nurses.There was almost universal support from nurses for the withdrawal decisions taken but there was disquiet expressed about the limited role nurses played in the decision-making. Concerns were raised about modes of treatment withdrawal, including manipulation of drug regimens and changes to patterns of ventilatory support, because of the perceived proximity to euthanasia. Nurses expressed sadness when they were frustrated in their efforts to give sufficient time, and optimal care, to patients and families. Satisfaction was associated with open debate within the multidisciplinary team. An important factor in nurses' coping strategy was a team philosophy and structure which fostered the support of nurses in the promotion of humanitarian values.From these data, five hypothetical case-study vignettes were devised, and questions were constructed around them to explore specific issues raised by nurses in phase one, 33 nurses from 2 ICU's participated in phase two. The data obtained confirmed concerns about quality-of-life assessment and euthanasia, and where patients have lost capacity, problems associated with consent and treatment-refusal.